Mentor Information Form

This form may be completed by individuals who achieved board certification in clinical neuropsychology through ABPP/ABCN and would like to offer their services as mentors to ABCN candidates. The data will be sent to Eric Waldron, PhD, ABPP, who is coordinating this AACN sponsored mentorship program.

ABCN Mentor Information Sheet

In what time zone do you practice?(Required)

Did you complete the Pediatric Subspecialty Certification through ABPP?(Required)

Yes

Would you be willing to mentor a candidate through the pediatric subspecialty process?(Required)

Yes

Candidates with ethnic backgrounds that are underrepresented in neuropsychology may request a mentor with a background similar to theirs. If you are from an ethnic group you consider to be underrepresented and are interested in working with a candidate with a similar background, please indicate your primary or preferred ethnic identification:

Other ethnic identification(Required)

Mentor's Contact Information

Name(Required)

First Last

Email(Required)

Enter Email Confirm Email

Phone

Year ABPP-CN Certification Achieved(Required)

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Mentee Match

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Mentor's Availability

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Mentor is Available

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Mentor is Matched

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Select Mentee to Assign

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Assigned Mentee

This field will be populated dynamically once you select a mentee to assign, change the mentor's status to Matched, and click the Update button below.

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Assigned Mentee ID

This field will be populated dynamically once you select a mentee to assign, change the mentor's status to Matched, and click the Update button below.

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Mentorship Start Date

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Mentorship End Date

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Additional Notes

Name

This field is for validation purposes and should be left unchanged.